Do Centers of Excellence Reduce Health Care Costs? Evidence From the US Veterans Health Administration Centers for Epilepsy

Kelly, Pat; Chinta, Ravi; Privitera, Gregory J.

doi:10.1002/joe.21632

Cited by 4 publications

(4 citation statements)

References 32 publications

(31 reference statements)

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“…For instance, the Veterans Affairs health care system is a large provider within the United States, yet performed 5 resections for epilepsy in 2019 and implanted 4 neurostimulators. 32 Therefore, our analysis likely reflects accurate data regarding major trends and the current state in epilepsy care in the United States.…”

Section: Discussionmentioning

confidence: 98%

United States Epilepsy Center Characteristics

et al. 2022

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Background and Objectives:Patients with drug resistant epilepsy (DRE) may benefit from specialized testing and treatments to better control seizures and improve quality of life. Most evaluations and procedures for DRE in the United States are performed at epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). On an annual basis, the NAEC collects data from accredited epilepsy centers on hospital-based epilepsy monitoring unit (EMU) size and admissions, diagnostic testing, surgeries, and other services. This article highlights trends in epilepsy center services from 2012 through 2019.Methods:We analyzed data reported in 2012, 2016, and 2019 from all level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level and center population category. EMU beds, EMU admissions, epileptologists, and aggregate procedure volumes were also described using rates per population per year.Results:During the period studied, the number of NAEC accredited centers increased from 161 to 256, with the largest increases in adult- and pediatric-only centers. Growth in EMU admissions (41%), EMU beds (26%), and epileptologists (109%) per population occurred. Access to specialized testing and services broadly expanded. The largest growth in procedure volumes occurred in laser interstitial thermal therapy (LiTT) (61%), responsive neurostimulation (RNS) implantations (114%) and intracranial monitoring without resection (152%) over the study period. Corpus callosotomies and vagus nerve stimulator (VNS) implantations decreased (-12.8% and -2.4% respectively), while growth in temporal lobectomies (5.9%), extratemporal resections (11.9%), and hemispherectomies/otomies (13.1%) lagged center growth (59%), leading to a decrease in median volumes of these procedures per center.Discussion:During the study period, the availability of specialty epilepsy care in the U.S. improved as the NAEC implemented its accreditation program. Surgical case complexity increased while aggregate surgical volume remained stable or declined across most procedure types, with a corresponding decline in cases per center. This article describes recent data trends and current state of resources and practice across NAEC member centers and identifies several future directions for driving systematic improvements in epilepsy care.

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Section: Discussionmentioning

confidence: 98%

United States Epilepsy Center Characteristics

et al. 2022

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“…For example, the VA health care system is a large health care provider within the United States, yet performed 4 resections for epilepsy in 2020 and implanted VNS in 8 patients. 26 Therefore, our analysis likely reflects accurate data regarding the state of inpatient epilepsy care in the United States in 2020.…”

Section: Discussionmentioning

confidence: 99%

Impact of the COVID-19 Pandemic on Epilepsy Center Practice in the United States

et al. 2022

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Objective:Persons with epilepsy, especially those with drug resistant epilepsy (DRE), may benefit from inpatient services such as admission to the epilepsy monitoring unit (EMU) and epilepsy surgery. The COVID-19 pandemic caused reductions in these services within the U.S. during 2020. This article highlights changes in resources, admissions and procedures among epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC).Methods:We compared data reported in 2019, prior to the COVID-19 pandemic and 2020 from all 260 level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level, center population category and geographical location. Qualitative responses from center directors to questions regarding the impact from COVID-19 were summarized utilizing thematic analysis. Responses from the NAEC center annual reports as well as a supplemental COVID-19 survey were included.Results:EMU admissions declined 23% (-21,515) in 2020, with largest median reductions in level 3 centers [-55 admissions (-44%)] and adult centers [-57 admissions (-39%)]. The drop in admissions was more substantial in the East North Central, East South Central, Mid Atlantic, and New England U.S. Census divisions. Survey respondents attributed reduced admissions to re-assigning EMU beds, restrictions on elective admissions, reduced staffing and patient reluctance for elective admission. Treatment surgeries declined by 371 cases (5.7%), with the largest reduction occurring in VNS implantations [-486 cases (-19%)] and temporal lobectomies [-227 cases (-16%)]. All other procedure volumes increased, including a 35% (54 cases) increase in corpus callosotomies.Significance:In the U.S., access to care for persons with epilepsy declined during the COVID-19 pandemic in 2020. Adult patients, those relying on level 3 centers for care and many persons in the eastern half of the US were most affected.

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“…Centers of excellence (CoEs) are specialized programs that supply high concentrations of expertise and related resources centered on particular medical areas and delivered in a comprehensive, interdisciplinary fashion (13). CoEs provide an opportunity to align physicians in quality improvement, reduce costs through greater efficiencies, and create market differentiation through clinical excellence and high patient satisfaction (14)(15)(16)(17)(18). CoEs also have the ability to dramatically enhance the depth and breadth of healthcare services available in communities that otherwise would not have had access to such exceptionally high levels of quality care (13).…”

Section: Introductionmentioning

confidence: 99%

Heartburn Center Set-Up in a Community Setting: Engineering and Execution

et al. 2021

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Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a “center of excellence” (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD.Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery.Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1–11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution.Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.

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Do Centers of Excellence Reduce Health Care Costs? Evidence From the US Veterans Health Administration Centers for Epilepsy

Cited by 4 publications

References 32 publications

United States Epilepsy Center Characteristics

United States Epilepsy Center Characteristics

Impact of the COVID-19 Pandemic on Epilepsy Center Practice in the United States

Heartburn Center Set-Up in a Community Setting: Engineering and Execution

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